Job Description
Job Description
POSITION : Home Health RN Field Case Manager
MAIN FUNCTION (Job Summary) :
A qualified Registered Nurse (RN) administers skilled nursing care to patients on an intermittent basis in their place of residence. This is performed in accordance with physician orders and plan of care under the direction of the Clinical Managers. Services are furnished in accordance with Wooster Community Hospital Home Health Services policies, Wooster Community Hospital policies, and Ohio Board of Nursing Scope of Practice regulations.
RESPONSIBLE TO (Job Relationship) :
- Supervised by : Director / Administrator, Clinical Managers
- Workers Supervised : LPNs, Home Health Aides
REPORTS TO (Reporting Responsibilities) :
Director / Administrator, Clinical ManagersMUST HAVE REQUIREMENTS (Job Qualifications, Experience, Education / Training, Professional License) :
Bachelor's DegreeCurrent State of Ohio driver’s licenseCurrent automobile insuranceProfessional licensure : State of Ohio RNAmerican Heart Association Basic Life Support (BLS) card currentAcceptance of philosophy and goals of Wooster Community Hospital and Home Health Services departmentAbility to exercise initiative and independent judgmentDemonstrated autonomy, accountability, and organization skills in performing / completing job responsibilitiesExcellent communication skillsKnowledge and ability to apply nursing processKnowledge and ability to apply community health principles and practicesDemonstrated ability to direct professional personnelAbility to work as a team memberPREFERRED ATTRIBUTES (Experience, Education / Training) :
Home care experienceComputer skills (keyboard, computer applications)Minimum of two (2) years nursing experience, preferredWORKING ENVIRONMENT :
Works indoors in the department office.Works in patient homes. Travels to / from patient homes.OTHER REQUIREMENTS (including Risk Exposure and Lifting Requirements) : Employees in this position may be :
Exposed to blood, body fluids and / or airborne pathogens.Required to don personal protective equipment, per Standard Precautions, and as applicable to the patient’s disease process.Able to participate in physical activity.Able to work for extended periods of time while standing and being involved in physical activity.Able to push, pull, lift, carry, turn, crouch, stand, and bend on a regular basis, as necessary to perform patient care and job duties.Required to take ‘On Call’ work shifts.Subject to STHR (short term hour reduction) according to scheduling policies.POSTION EXPECTATIONS (Responsibilities & Job Duties) :
Leadership
Accepts and responds to change productively, while maintaining a positive attitudeDemonstrates conflict resolution skillsReports actual and near-miss adverse events to Director / Administrator, or designee, in a timely mannerSpeaks positively of the department to customers, referral sources, and community healthcare partnersCommunication
Maintains awareness of verbal and non-verbal communication during interactions with coworkers, patients, caregivers, health care providers, and health care vendorsMaintains patient confidentiality in all communication interactions : written, verbal, electronic, and digitalCollaborates and communicates effectively with all interdisciplinary team members (handoff communication, interdisciplinary care coordination)Reports critical information to physician and other team members, as indicatedUtilizes chain of command to handle issuesParticipates in care coordination communication(s), including handoff communicationDemonstrates basic ability to initiate and manage crucial conversationsUtilizes AIDET (Acknowledge, Introduce, Duration, Expectations, Thank You) strategies to foster positive communication among all interdisciplinary team members, coworkers, health care providers, health care vendors, and studentsOperations
Follows all Infection Prevention strategies, including hand hygieneCompletes and submits OASIS assessments, reassessments [ recertification, follow-up], transfers, resumptions of care, discharges, and significant change of condition as defined by department documentation guidelinesAssumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, patient representative [if any], caregiver(s)Determines the amount and type of nursing needed by each individual patient, in conjunction with the interdisciplinary team members, physician, patient, caregiver, and patient representative
Initiates the plan of care.Initiates appropriate preventive and rehabilitative nursing proceduresCoordinates services (field case management)Refers to Physical Therapist, Speech Language pathologist, Occupational Therapist, Medical Social Worker, and Home Health Aide those patients requiring their specialized skills
Communicates to interdisciplinary team members patient’s care needs, teaching to be completed, plan of care revisions, and new physician orders.Conducts initial evaluation visit and regularly reevaluates the patient’s nursing needs.Revises patient individualized plan of care, as necessary
Conducts supervisory visits. Provides feedback to LPN and / or HHA, as necessaryAccurately performs a multisystem patient assessmentObserves signs and symptoms reported by the patient and / or caregiverObserves patient’s response to treatments, education, and medicationsProvides patient care / procedures (services) ordered by the physician, as indicated in the plan of care (485) and patient individualized goals & interventions, according to department & organization procedures, as assignedProvides those services requiring substantial specialized nursing skills
Gives total patient care, as neededProvides patient and caregiver education (teaching), utilizing patient teaching resources approved by Wooster Community Hospital and / or Home Health Services leadershipAssess patient and caregiver knowledge of teaching utilizing teach-back and return demonstration strategiesProcesses & documents physician orders.Completes certification / recertification orders and transfer / discharge summaries.Accurately documents assessments, interventions, response to interventions, response to teaching, and progress towards goals (outcomes) in the medical recordCommunicates (reports) with interdisciplinary team members, including the physician(s), the patient’s progress towards goals, response to treatments, change in condition [if any], new signs & symptoms for the patient, and / or revisions in plan of careCollaborates with Clinical Managers and other disciplines to prepare patient for discharge once patient-specific, individualized, goals are metLeads / participates in the interdisciplinary coordination of care conversations / care planning for patients assigned to their careNotifies the Clinical Manager and / or Scheduler, or designee, of patient visit schedule changes in a timely mannerCompetently performs skills / job responsibilities listed on standard work / skills list for job position.Coordinates work to achieve maximum productivity. Able to multitask and prioritize workload. Work habits are consistently adjusted to accommodate multiple responsibilities. Responsibilities are prioritized and completed in a timely manner.Demonstrates reasonable and rational judgment in decision making.Maintains equipment and supplies in proper working order. Reports issues to Clinical Manager and / or Director / Administrator.Customer Service
Displays positive attitude. Treats others with honesty and respect. Speaks positively in all customer interactions internal and external.Uses AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You) to :Optimize the patient’s experience by reducing the patient and caregiver’s anxiety
Increase patient complianceDevelop positive relationships with other employees, health care providers, and health care vendorsAssesses customer satisfaction during interactions.Maintains positive working relationships with coworkers, referral sources, and healthcare providersUses appropriate chain of command for unresolved issues or problems.Uses face-to-face resolutions (crucial conversations) to intervene with patients, caregivers, health care providers, vendors, students, and / or coworkers in situations where customer needs have not been met to determine a positive, mutually agreeable resolution.Staff Development / Personal Growth
Attends department meetings, educational activities, and inservicesSupervises and teaches other nursing personnelDemonstrates initiative and responsibility to develop personal and professional goals.Demonstrates professional growth by maintaining awareness of changes in home care industry.Demonstrates professional growth by maintaining awareness of applicable professional best practices.Accepts feedback as opportunity for growth.Demonstrates knowledge and understanding of new policies & procedures, practices / standard work, and initiatives. Obtains this knowledge via attending staff meetings, reading paper & electronic communications, plus completing required hospital & home health education.Maintains professional license.Performance Improvement (QAPI; Quality Assessment & Performance Improvement Program)
Maintains awareness of CMS conditions of participation and accreditation standards.Reviews home care patient satisfaction survey, value based purchasing, and 5 Star Rating data, as distributed by home health leadership.Participates in QAPI projects : identifies processes to be improved, communicates ideas to home health leadership, assists in process flowcharting & brainstorming, collects data [if assigned], attends education on new processes, and incorporates new processes in job performance.Participates in data collection and chart audit(s), as assignedEmbraces change in the home care practice environment so as to optimize patient outcomes while maintaining financial stabilityAGE SPECIFIC COMPETENCY : Adults and Geriatrics (18 years and older)
Identifies physical, social, cultural, and emotional barriers plus physical limitations throughout episode of careIntegrates patient’s barriers and limitations in individualized plan of careTeaches patient about one topic / item at a timeRepeats instructions several timesSpeaks slowly and distinctly when talking to the patientEmployee Attestation of Receipt and Understanding of Job Description :
I have read the above job description and fully understand the conditions specified in this document.I will perform these duties to the best of my knowledge and ability.I will adhere to Wooster Community Hospital policies & procedures, Wooster Community Hospital Home Health Services policies & procedures, Home Health Scheduling Guidelines, and Wooster Community Hospital Employee Handbook.Employee Signature : ______________________________________________ Date : __________
4- ten hour shifts
40 hours
